Provider Demographics
NPI:1720840044
Name:JACKSON, LETISHA S
Entity Type:Individual
Prefix:
First Name:LETISHA
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2885 MCCULLOUGH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-9022
Mailing Address - Country:US
Mailing Address - Phone:662-231-1813
Mailing Address - Fax:
Practice Address - Street 1:2885 MCCULLOUGH BLVD STE B
Practice Address - Street 2:
Practice Address - City:BELDEN
Practice Address - State:MS
Practice Address - Zip Code:38826-9022
Practice Address - Country:US
Practice Address - Phone:662-231-1813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies